one year 4 month wait

[fatbottomgirl 0]

My insurance is Anthem PPO and Im going to an info meeting in two weeks. Ive considered getting lap band for the last few years, but ive finally worked up enough courage to call and get information and go to a meeting.

I just found out that according to my insurance, I must be employed with my employer for 3 years before weight loss surgeries can be approved. And after the 3 year waiting period, weight loss surgery is only covered 50/50. Ive only been there a year and 6 months. So my question is, while Im waiting, what can I do? Should I see if I can do the psych eval/nutrition classes while Im waiting? Just looking for thoughts or anything that I can do to try to get through this seemingly endless process. Has anyone else had issues like this? What did you do?

[HappyMom 1]

I am really sorry that you are having a problem with Anthem. I too have Anthem BCBS PPO and haven't had any problems with them at all. I am not sure if there are any guidelines that we had to follow about length of employment. My husband has worked for his company for longer than 3 years, but we have only had Anthem for just a little over a year (changed for the 2009 calendar year).

My surgery is scheduled for two days from now and I only have to pay $100 for the procedure. This is of course after I meet my out of pocket deductible for the year. Since we are not there yet the actual cost is $850. ($100 for the surgery and $750 for our remaining family deductible).

I have befriended the insurance processor at the hospital since I have bugged him so much over the last month about my application status. He said that he is noticing that certain employers are putting restrictions on weight loss surgery that are more stringent than the insurance companies requirements. The patients would normally be getting approved (and approved faster) if not for the clauses that some companies make regarding WLS. I personally think that this is bogus, but it seems to be the trend.

It sounds like it might be your employer that is restricting the qualifications and payments for your surgery. I have not talked with another person who has carried Anthem that didn't breeze through the approval process. Maybe you can talk to your benefits department at your company and see if they can do anything for you.

I really wish you good luck in your approval process!

[BetsyB 9]

How frustrating!

Have you thought about approaching HR to see if the policy can be changed? Most employers renew policies annually, and do have the ability to make such changes.

Most believe (wrongfully) that weight loss surgery is tremendously expensive. In fact, the healthcare costs associated with morbid obesity are far higher. And then, from an employer standpoint, there is also stuff like missed work.

Adding more liberal coverage for bariatric surgery can be presented as a cost-saver!

In terms of what to do while you wait, I'd hold off on seeing all of the ologists until your surgeon asks you to do so. Many times, surgical clearance can only be a certain "age" (for example, no more than three months or six months old).

Good luck--don't give up hope!

[HappyMom 1]

I definitely agree with Betsy about trying to get the insurance company to consider the surgery a long term cost saver.

I take a total 5 medications associated with my diabetes and high blood pressure. The total monthly cost of these medications is $450/month. That is a staggering $5400 a year! My primary care doctor is certain that I will be off of ALL medications within 6 months...if not sooner!

The total cost for the insurance company for the next ten years is $54K. I am not sure of the cost of the surgery if you are self-pay ($15K or so), but my insurance company can probably break even within 3 years time.

I think that the insurance companies need to come around to the notion that WLS is a money saver for them in the long run.

[HiMow 0]

aww I had to wait a year and 2 months :smile: I feel your pain, but hang in there!

[jdonnajay 0]

i wouldnt go to any specialty doctors unless you know you will be having surgery within that year..most insurance companies want all records to be within a year..i submitted a claim and was denied because my pychol. report was 1 yr and 2 months old..appealed with new report updated and was approved..good luck !!

[LoserHeather37 5]

aww I had to wait a year and 2 months :smile: I feel your pain, but hang in there!

Wow, you've lost 80 pounds in 4 months? That gives me the encouragement that I needed while on day 3 of my 14 day liquid diet!!! You go girl!!!:thumbup: